Lipco Input Form

If you have any problems in completing this
online form, please click here for assistance

Your personal details:

Title (Mr, Mrs, Miss, Dr, Prof, etc):

Surname:

First names:

ID Number:

Postal Address:

Postal Code:

Please note: at least one contact number is required!
Use this number in all three fields if no other contact numbers

Telephone No: Home
(include area code)

Telephone No: Work
(include area code)

Cellphone No:

E-mail address:

Employer:

Marital Status: (Married, Single, Divorced, Widow/Widower, Co-habitating):

Your spouse's details:

Surname:

First Names:

Date of birth (dd/mm/YYYY):

Your children's details:

Please enter the details of your children (if applicable) in the fields below. 4 Eldest dependant children (unmarried & unemployed) under the age of 21 years.

Child 1

Surname:

First Names:

Child 3

Surname:

First Names:

Child 2

Surname:

First Names:

Child 4

Surname:

First Names:

Your Extended Family details:

Member 1

Surname:

First Names:

Contact Number

Relation (ie Mother)

Member 3

Surname:

First Names:

Contact Number

Relation (ie Mother)

Member 2

Surname:

First Names:

Contact Number

Relation (ie Mother)

Member 4

Surname:

First Names:

Contact Number

Relation (ie Mother)

Packages

Benefit Table:

Please tick the appropriate premium applicable to you

Membership	Membership Fee p.m.	Litigation Benefit Limit p.a.	Selection
Platinum Plus	R 239.00	R 240 000.00	YES
Platinum	R 179.00	R 180 000.00	YES
Gold	R 109.00	R 110 000.00	YES

Add: Extended Family Plan for only R49.00 p.m.			YES

Please NOTE: First months premium will include an administration fee equal to one months premium

Submit

Click on the submit button to send your form to us, or alternatively, click on reset to clear all information.